Medicine

Lean practices and starting a trauma center.

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The discussion of the pharmacy reorganization got me thinking of the trauma center that we started in 1979. That was well before I learned about lean practices or the Toyota method but I think we used a number of their principles anyway.

When we started our trauma center, we did something a bit like your pharmacy project. We were a small hospital (120 beds) in a new suburban area with the ocean on one side and national parks and mountains on the other. Orange County narrows down to a triangle which ends at San Clemente where the Marine base begins. We knew the county was going to regionalize trauma. A study had come out suggesting that too many people died because “the golden hour” was lost in trying to get doctors and operating rooms organized, especially at night.

Several large hospitals planned to enter a competition to qualify as centers; one of course, was the UCI medical center. None of them was within 25 miles of our hospital. We didn’t like the idea of seeing the injured patients, some of whom would be neighbors, being taken that far and we looked to see if we could set up a trauma center for our community that would pass muster with the EMS survey team. First we had to see if the hospital and medical staff would support it. My partner and I couldn’t do it alone.

I did a study of the finances of trauma. The stereotype is a drunken insolvent who is stabbed or shot. Our community is located along I-5 where it runs from Los Angeles to San Diego. We are between mountains and the sea. I took the records of all emergency admissions, who went to surgery or who were discharged with a “surgical” diagnosis and who went to ICU. Some of those were general surgery but by using a screen we got down to the trauma cases. I found that 85% of them had some sort of insurance. This was largely because most were auto accidents. Even if people don’t carry health insurance, somebody may have medical benefits with car insurance.

We presented this to the department of surgery and they turned us down flat. The vote was something like 33 to 2. We went to the Board of Trustees. At the time, the hospital was owned by a partnership, one of the dreaded for-profit hospitals. The Board was easily convinced that this was something we needed to do if this hospital was going to grow. Southern California is cursed with many small hospitals and few big ones outside of Los Angeles. I knew a vascular surgery group, of three men, in the San Fernando Valley that went to 12 hospitals. One of the reasons I moved to Mission Viejo was to get out of Los Angeles.

Anyway, we had the hospital on board but not the doctors. The hospital decided to make the trauma center a contract service like the ER. My partner and I would run it. The hospital hired a city planner to draw up a proposal for the county. They gave me a copy when he was finished and it was the size of a Chicago telephone book. I read through it and it sounded like a proposal for a shopping center. I rewrote it. A lot of it was useful, like traffic analysis, but the vast majority didn’t answer the right questions.

Then we had to figure how we could do this and not go broke. There were two of us. We would call other specialists, like orthopedists and neurosurgeons, as needed. That’s how we got around the surgery department. There were grumbles but they faded as the orthopods began to realize that trauma cases paid well, mostly. Then we figured out who is in the hospital at night. The other trauma center candidates all promised to have a surgeon and anesthesiologist in-house 24 hours per day. We could not afford that. We promised that the surgeon and anesthesiologist would arrive within 15 minutes of being called, usually before the victim. The ER doc would be there. That was just as Emergency Medicine was becoming a specialty and our ER docs were GPs.

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Computation and Reality

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Present-day computers are remarkably fast…a garden-variety laptop can do over a billion basic operations (additions, multiplications, etc) every second. The machine on which you are reading this can do more calculating, if you ask it nicely, than the entire population of the United States. And supercomputers are available which are much faster.

Yet there are important problems for which all this computational capacity is completely inadequate. In their book Natural Computing, Dennis Shasha and Cathy Lazere describe the calculations necessary for the analysis of protein folding…which is important in biological research and particularly in drug design. Time must be divided into very short intervals of around one femtosecond, which is a million billionth of a second, and for each interval, the interactions of all the atoms involved in the process must be calculated. Then do it again for the next femtosecond, and the next, and the next…

To perform this calculation for one millisecond of real time (which is apparently a biologically-interesting interval) would require 100,000 years on a conventional computer.

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Education and traditions.

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In my years in medicine, which began in 1961 or even earlier with premed, I met a few very colorful teachers. From time to time, I would like to profile some of them lest they be forgotten as people and remain only an entry in a dusty bound volume in a library. One such was a neurosurgeon named Aidan Raney. When I began to do a little research on him, I found that Google searches turn up only his son, a very good cardiac surgeon in Newport Beach. I remember the son as a high school student I met once.

When I was a third year medical student, my medical school had a program in which students could spend a summer with private practice physicians to see what the life was like. I spent a summer with Aidan Raney. I wasn’t so much interested in neurosurgery but wanted to see more of it before I committed myself to a career. Doctor Raney had been the first neurosurgery resident at the new Los Angeles County Hospital after it opened in 1933. The old hospital, now torn down, had been in service since about 1913. The University of Southern California medical school, which had closed in 1920 as a consequence of the Flexner Report, reopened when the new hospital opened and graduated its first class in 1932.

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Bubble-icious — American History and Political Subsidies

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As someone who’s written several times (here and here) about the course of modern health care (its inherent complexity and cost), I’ve been watching the latest moves in US health care funding with a great deal of interest.

From the introduction of antibiotics to the breakthroughs in transplant surgery, medicine in the 20th century was in a position to provide dramatic improvements in health care (both quality of life and length of life) at relatively modest cost. Many consider it a golden age in medicine. My personal belief is that medical care is about to hit another burst of creativity and success (but at much higher cost-to-benefit) as non-invasive imaging, micro-surgery, diagnostic testing, and DNA-propelled pharmaceutical customizations kick in. I may be wrong, but I think my beliefs are a reasonable extrapolation of the trends in medical care since the end of the 1970s “silver bullet” period of medicine.

So what do my guesses about modern medicine mean in a new era of greater tax subsidies for US health care? An era which, by necessity, must politicize health care further. It got me to thinking about the hidden subsidies during earlier periods of American history, powered by the domestic political systems of the time, and driven by citizen/voter appetites. And it got me thinking about the law of unintended consequences.

After a few minutes scribbling on the back of an envelope, I came up with the following:

US Bubbles Over Four Centuries

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Mini-Book Review — Groopman — How Doctors Think

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Groopman, Jerome, How Doctors Think, Houghton Mifflin, 2007.

This book is several years old but deals with timeless subject matter that might be of interest to cb readers. In the past decade or two, a major initiative called evidence-based medicine (EBM) has tried to improve how medical research is conducted and how it is used in everyday clinical practice. It’s the application of the scientific method (with all its strengths and weaknesses) to confirming how we know what we know about medical practice. Some examples of such efforts “organized improvement” were covered in a book I reviewed earlier on cb called Better: A Surgeon’s Notes on Performance by Atul Gawande. Like Dr. Gawande, Dr. Groopman writes extensively for the New Yorker. The resulting quality and clarity of his writing in How Doctors Think stands out. Either he or his editors are very good.

In How Doctors Think, the author looks at a very different avenue of medical improvement. Deductive, evidence-based, medicine necessarily involves many patients and the careful collection of information about how a treatment works for large numbers of people. This is the foundation for proving the efficacy of particular treatments for particular populations, and winnowing out cases where doctors are “fooling themselves” about their treatment. Not fooling ourselves, as physicist Richard Feynman once pointed out, is one of the great challenges of science. The folks doing EBM research always give themselves a good laugh by evaluating the mathematical and statistical skills of the average GP. Interpreting the scientific medical literature is a real skill. One that needs to be taught and reinforced. As a baseline, we can aspire for a medical profession that can dependably read, critique, and interpret its own research.

The inductive process of forming a diagnosis and executing treatment with a specific patient benefits mightily from the disciplined research of EBM, but it by no means replaces the services of skilled physicians. Checklists or AI applications in medicine can reduce egregious errors, but human judgment, matched with experience and rigorous thinking, are necessary components of health care. And that’s the focus of Groopman’s book.

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